Back to Chapter 4 Table of Contents Covered
Not Covered
Benefits
CC & IFP
Details and Limitations
EG
Outpatient Surgery Physician/Surgical Services
Phenylketonuria (PKU)
Prescription Drugs: Generic/Preferred Brand/ Non-Preferred Brand/ Specialty
Previously Prescribed Prescription Drugs
Prescriptions filled at an out-of-network pharmacy are covered if related to care for a medical emergency or urgently needed care. If the requested prescription is not listed on the formulary, a prior authorization is required. Refer to VHP’s preferred medication formulary for drug benefit coverage: https://www.valleyhealthplan.org/sites/m/pn/Pharm/ Pages/Pharmacy.aspx
Refer to Chapter 16, “Pharmacy Services.” Preventive and immunization services are covered services in accordance with the Centers for Disease Control (CDC), Preventive Services Task Force A and B guidelines.
Preventive Care/Screening/ Immunization
Refer to the U.S. Preventive Services Task Force for a complete list of preventive services: https://www.uspreventiveservicestaskforce.org/Page/ Name/uspstf-a-and-b-recommendations/ Travel health immunization consultations are not a covered benefit.
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2021 / Provider Manual
CH 4: Member Benefits, Exclusions, & Limitations
